1. I am a petitioner seeking correction of the clerical error in:

b) The Certificate of Live Birth of who is my daughter

2. I/He/She was born on _________________________ at

3. The birth was recorded under registry number __________________________________.

4. The clerical error(s) to be corrected is (are):

Item No. Description From To

5. The facts/reasons for filling this petition are the following:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. I submit the following documents to support this petition:a) ________________________________________________________________________b) ________________________________________________________________________c) ________________________________________________________________________d) ________________________________________________________________________

7. I have not filed and similar petition and that, to the best of my knowledge, no longer similarpetition is pending with any LCRO, Court or Philippine Consulate.

8. I am filing this petition at the LCRO of Iloilo City, Province of Iloilo in accordance with RA No.9048 and its implementing rules and regulations.

__________________________________ Signature over printed name of petitioner

VERIFICATION

I, ____________________________________, the petitioner, hereby certify that the allegations

herein are true and correct to the best of my knowledge and belief.

______________________________ Signature over printed name of petitioner

SUBSCRIBED AND SWORN to before me this ___________ day of _____________________

Doc. No. ________________

For C/MCR use only

ACTION TAKEN BY THE C/MCRGranted Denied (Provide the basis for denial.)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________